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Rural congestive heart failure mortality among US elderly, 1999–2013: Identifying counties with promising outcomes and opportunities for implementation research
  1. Maria C. Mejia de Grubb1,
  2. Robert S. Levine1,
  3. Barbara Kilbourne2,
  4. Baqar A. Husaini3,
  5. Tyler Skelton1,
  6. Lisa Gittner4,
  7. Michael A. Langston5 and
  8. George E. Rust6
  1. 1.Department of Family and Community Medicine, Baylor College of Medicine, Houston, TX, USA
  2. 2.Department of Sociology, Tennessee State University, Nashville, Tennessee, USA
  3. 3.Center for Prevention Research, Tennessee State University College of Agriculture, Nashville, Tennessee, USA
  4. 4.Department of Political Science, Texas Tech University, Lubbock, TX, USA
  5. 5.Department of Electrical Engineering and Computer Science, University of Tennessee, Knoxville, Tennessee, USA
  6. 6.Department of Family Medicine, National Center for Primary Care, Morehouse School of Medicine, Atlanta, Georgia, USA
  1. Corresponding Author: Maria C. Mejia de Grubb, MD, MPH, Department of Family and Community Medicine, 3701 Kirby Drive, Suite 600, Houston, TX 77098, USA, Tel.: +713-798-4735, E-mail: Maria.MejiadeGrubb{at}


Objective Describe modern trends in congestive heart failure (CHF) among elderly (>65 years of age) in the United States, to identify potentially successful rural areas. Compare CHF mortality using multiple- (MCOD) versus underlying-(UCOD) cause of death data.

Methods U.S. Centers for Disease Control and Prevention mortality files (WONDER internet site).

Results Using MCOD data, overall mortality rates/100,000 population (and 95% confidence intervals) for CHF among persons >65 years of age (1999–2013) were 482.0 (481.2–482.8) for large central and large fringe metropolitan (LCLF) counties, 549.6 (548.6–550.7) in small and medium metropolitan (SM) counties, and 652.6 (650.9–654.0) in micropolitan and non-core, non-metropolitan (MNCNM) counties. Twenty positive deviance NCNM counties (collectively including 198,581 residents >65 years of age) had an overall CHF rate of 300.9 (275.0–326.9) in 2013. This was significantly lower than the LCLF rate for 2013 (482.0 [481.2–482.8]), and represented a reduction of 47% since 1999. Overall CHF occurrence as estimated with MCOD was 3.4-fold higher than that obtained with UCOD.

Conclusion These data illustrate underestimation of CHF by UCOD data and the importance of correct death certification. Rural CHF mortality rates are higher than urban rates, but some positive deviance counties demonstrate that this is not inevitable. Further research is needed to understand the relative contribution of research innovation, medical care, and public health to rural-urban disparities and the relative success of positive deviance counties.

  • Congestive heart failure
  • elderly
  • mortality
  • rural

This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 Unported License (CC BY-NC 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. See

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